Page 19 - University of Martland Nursing Forum - Winter 2017

Fornili says one of the most important of the 12 recommendations in the guideline is the need for health care providers to involve patients in all decision-making and treatment goals, focusing on the known risks and realistic benefits of opioid therapy. Fornili is helping students prepare for this critical communication with patients, drawing on her own experiences in the field to inform those lessons.
Prior to coming to UMSON in 2005, Fornili had worked for more than 13 years in managerial, administrative,
and consultative roles in city, state, and federal governments regarding the care of individuals with substance-use disorders. She is also associate editor of and writes for the Journal of Addictions Nursing.
“All of these experiences help inform
my teaching, especially in the addictions course and my community/public health clinical groups,” Fornili says.
The addictions course is NURS 418: Drug Addiction, Society, and the Role of the Nurse, which Fornili co-teaches and is designed to help undergraduate students develop the knowledge, skills, and attitudes necessary to ensure that nurses in all health settings meet a basic level of competency for screening and intervening with individuals with substance-use disorders.
Fornili also teaches two undergraduate community/public health nursing groups in a clinical practicum in downtown Baltimore. The practicum site is a residential job-training program for formerly homeless men, many of whom have histories of incarceration and are in the early stages of recovery from alcohol or drug dependence.
She works with master’s-level students on their papers and with doctoral students on their projects, especially when they relate to addictions. “Last spring, I mentored a student whose clinical nurse leader paper focused specifically on the use of naloxone [a medication used to block the effects
of opioids] to prevent opioid overdose deaths,” she says. And UMSON’s
Students United for Policy, Education, and Research group has also been involved in school-sponsored sessions for students to learn more about naloxone administration.
Advanced practice nursing students, including nurse practitioners, get more than 500 hours of direct patient care under the supervision of an experienced master’s- or doctorally prepared practitioner regarding safe, effective prescribing practices consistent
with the CDC guideline and other national standards.
“In certain situations, it is also important for clinicians to discuss the difference between immediate-release opioids and extended-release opioids, which take longer to be fully effective,” Fornili says. “If patients are unaware of this distinction, they may take more medication than prescribed to relieve pain.”
The CDC guideline notes that certain screening measures implemented by hospitals may have had unintended consequences. While states’ prescription- drug monitoring programs can notify a health care provider if an individual has been “doctor shopping” for prescription drugs, and urine tests can indicate whether a patient is also abusing
other drugs or alcohol, the difficulty in obtaining prescribed opioids may turn some individuals to heroin, which has similar effects but is less expensive and, in some cases, easier for people to obtain. According to NIDA, nearly half of young people who inject heroin reported using prescription opioids before the onset of heroin use.
Kay Mathias, BSN ’86, CRNP, a neonatal nurse practitioner at Mount Washington Pediatric Hospital in Baltimore, has witnessed firsthand the effects of heroin and other opioid abuse. She says that
with the majority of substance-exposed newborns she sees, the mother is in
a methadone program because it is considered unsafe to withdraw women from opioids during pregnancy. Many became addicted to painkillers after
surgery. “They were given a 30-day supply and had no idea that they could become addicted,” says Mathias, indicating that opioid addiction is evident throughout Maryland, not just in Baltimore, and
that some babies are born addicted to the methadone used to treat the opioid addiction. “I believe it’s important to have prenatal education for those in a methadone program so that they know what to expect when their baby goes through withdrawal.”
Mathias says that symptoms of neonatal abstinence syndrome (NAS), the clinical term for the problems that occur in newborns exposed to addictive drugs while in the womb, include gastrointestinal complications, such as diarrhea, gas, and abdominal pain, and central nervous system components, including irritability, inability to sleep, a harsh pitch to the baby’s cry, fever, and a high respiratory rate. According to Mathias, the half-life
for methadone withdrawal is longer than heroin’s, and exactly when a baby begins to withdraw can vary. Each infant responds differently, depending on when the mother last used the opioid, the amount the mother was taking, the size of the infant, how fast the baby excretes the drug, and other variables, so nurses like Mathias use a spectrum of care, depending on how the baby responds.
“We will initially try supportive measures, such as a dark, quiet room with decreased stimulation, soft music, swaddling, and a vibrating infant bed,” Mathias says. “If this does not prove to be effective, enough morphine will be administered to avoid serious withdrawal symptoms and seizures, and then the amount will be decreased.”
This can lead to lengthy, costly hospital stays for the babies. And the statistics related to NAS are as staggering as those related to nationwide opioid overdose deaths. According to the National Institutes on Drug Abuse, more than 21,000 infants were born in the United States with NAS in 2012. That’s equivalent to one baby born suffering from opiate withdrawal every 25 minutes.
UNIVERSITY OF MARYLAND SCHOOL OF NURSING 17